Transition Final
A client has just had a cast removed and the underlying skin is yellow-brown and crusted. The nurse determines that further instructions are needed about skin care if the client makes which statement? 1."I will soak the skin and then wash it gently." 2."I need to scrub the skin vigorously with soap and water." 3."I need to apply an emollient lotion to enhance softening." 4."I need to use a sunscreen on the skin if it will be directly exposed to the sun."
2."I need to scrub the skin vigorously with soap and water."
To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care? 1.Initiating seizure precautions 2.Using a wheelchair for out-of-bed activities 3.Assisting the child with ambulation at all times 4.Avoiding contact with other children on the nursing unit
1.Initiating seizure precautions
During data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe? 1.A fear of leaving the house 2.A fear of riding in elevators 3.A fear of speaking in public 4.A fear of uncleanliness and the need to bathe every hour
1. A fear of leaving the house
The nurse is explaining causes and reasons of hemophilia A to the parents of a child with the disease. The nurse should make which statement about hemophilia A? 1."Hemophilia A is a Y-linked hereditary disorder." 2."Hemophilia A results from a deficiency of factor IX." 3."Hemophilia A results from deficiency of factor VIII." 4."Hemophilia A is always inherited in a recessive manner."
3."Hemophilia A results from deficiency of factor VIII."
The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care to a client. Which instructions should be included in the list? Select all that apply. 1. Restrict fluid intake. 2. Obtain a Medic-Alert bracelet. 3. Keep the humidity in the home low. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6. Avoid swimming and use care when showering.
2. Obtain a Medic-Alert bracelet. 4. Prevent debris from entering the stoma. 5. Avoid exposure to people with infections. 6. Avoid swimming and use care when showering.
The nurse is reinforcing instructions to the parents of an infant with clubfoot about the care of a plaster cast. Which statement should the nurse include in the instructions? Select all that apply. 1."The cast can be cleansed with a wet cloth on the outside." 2."The foot should be kept elevated for the first 24 to 48 hours." 3."The cast will dry in 30 minutes so it can be handled after that time." 4."Reposition the infant every 2 to 4 hours until cast is thoroughly dried." 5."The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."
2."The foot should be kept elevated for the first 24 to 48 hours." 4."Reposition the infant every 2 to 4 hours until cast is thoroughly dried." 5."The edges of the cast can be 'petaled' with small pieces of moleskin or adhesive tape."
The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1.Provide a cool environment for the client. 2.Instruct the client to consume a high-fat diet. 3.Instruct the client about thyroid replacement therapy. 4.Encourage the client to consume fluids and high-fiber foods. 5.Inform the client that iodine preparations will be prescribed to treat the disorder. 6.Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.
3.Instruct the client about thyroid replacement therapy. 4.Encourage the client to consume fluids and high-fiber foods. 6.Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.
The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome? 1.The condition is characterized by above-average intellectual functioning with deficits in adaptive behavior. 2.The condition is characterized by average intellectual functioning and the absence of deficits in adaptive behavior. 3.The condition is characterized by subaverage intellectual functioning with the absence of deficits in adaptive behavior. 4.The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).
4.The condition is congenital and results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G).
The nurse is preparing to administer 35 mg of a prescribed intramuscular (IM) dose of medication to a client. The medication label reads 50 mg/mL. How many milliliters should the nurse administer to the client? Fill in the blank.
0.7mL
A postoperative client has a prescription to receive an intravenous (IV) infusion of 1000 mL normal saline solution over a period of 10 hours. The drop (gtt) factor for the IV infusion set is 15 gtts/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank.
25 gtt/min
The nurse is assisting with collecting data on a child with seizures. The nurse is interviewing the child's parents to establish their adjustment to caring for their child with a chronic illness. Which statement by the parents indicates a need for further teaching? 1. "Our child sleeps in our bedroom at night." 2. "We worry about injuries when our child has a seizure." 3. "Our child is involved in a swim program with neighbors and friends." 4. "Our babysitter just completed first-aid and child resuscitation training."
1. "Our child sleeps in our bedroom at night."
The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence? 1.Cause hemorrhage 2.Initiate premature labor 3.Rupture the fetal membranes 4.Increase the chance of infection
1. Cause hemorrhage
The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions? 1.Maintain a high fluid intake 2.Discontinue the medication when feeling better. 3.If the urine turns dark brown, call the primary health care provider (PHCP) immediately. 4.Decrease the dosage when symptoms are improving to prevent an allergic response.
1.Maintain a high fluid intake
The nurse prepares to administer a prescribed dose of scopolamine. The nurse should monitor for which side effect of this medication? 1.Dry mouth 2.Diaphoresis 3.Excessive urination 4.Pupillary constriction
1. Dry mouth
The nurse is preparing to administer digoxin, 0.125 mg orally, to a client with heart failure. Which vital sign is most important for the nurse to check before administering the medication? 1.Heart rate 2.Temperature 3.Respirations 4.Blood pressure
1. Heart rate
The nurse is caring for a client dying of cancer. During care, the client states, "If I can just live long enough to attend my daughter's graduation, I'll be ready to die." Which phase of coping is this client experiencing? 1.Anger 2.Denial 3.Bargaining 4.Depression
3. Bargaining
The nurse should implement which actions in the care of a child who is having a seizure? Select all that apply. 1.Time the seizure. 2.Restrain the child. 3.Stay with the child. 4.Insert an oral airway. 5.Place the child in a supine position. 6.Loosen clothing around the child's neck.
1. Time the seizure 3. Stay with the child 6. Loosen clothing around child's neck
Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)? 1.U waves 2.Flat P waves 3.Elevated T waves 4.Prolonged PR interval
1. U waves
The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply. 1.Apply disposable gloves. 2.Place the client in the right Sims' position. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 5.Hang the enema solution container 24 inches above the client's anus. 6.Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).
1.Apply disposable gloves. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 6.Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).
A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply. 1.Monitor vital signs. 2.Monitor intake and output. 3.Increase water intake orally. 4.Monitor electrolyte levels. 5.Provide a sodium-reduced diet. 6.Administer sodium replacements.
1.Monitor vital signs. 2.Monitor intake and output. 3.Increase water intake orally. 4.Monitor electrolyte levels. 5.Provide a sodium-reduced diet.
The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.
17 gtt/min
The nurse is planning to administer amlodipine to a client. The nurse should plan to check which before giving the medication? 1.Respiratory rate 2.Blood pressure and heart rate 3.Heart rate and respiratory rate 4.Level of consciousness and blood pressure
2. Blood pressure and heart rate
A client has had skeletal traction applied to the right leg and has an overhead trapeze available for use. The nurse should monitor which area as a high-risk area for pressure and breakdown? 1.Scapulae 2.Left heel 3.Right heel 4.Back of the head
2. Left heel
The nurse is caring for a client with a diagnosis of pemphigus. The nurse should include which interventions in the plan of care for the client? Select all that apply. 1.Administering prescribed acyclovir 2.Applying prescribed topical antibiotic 3.Administering prescribed corticosteroid 4.Administering prescribed oral amphotericin B 5.Applying Domeboro solution to the affected skin
2.Applying prescribed topical antibiotic 3.Administering prescribed corticosteroid 5.Applying Domeboro solution to the affected skin
The nursing instructor asks a student to describe the pathophysiology that occurs in Cushing's syndrome. Which statement by the student indicates an accurate understanding of this disorder? 1."Cushing's syndrome is characterized by an oversecretion of insulin." 2."Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones." 3."Cushing's syndrome is characterized by an undersecretion of corticotropic hormones." 4."Cushing's syndrome is characterized by an undersecretion of glucocorticoid hormones."
2."Cushing's syndrome is characterized by an oversecretion of glucocorticoid hormones."
The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement? 1."Do you feel guilty about your child's weight gain?" 2."In most cases, medication and diet will control fluid retention." 3."Wearing loose-fitting clothing should help conceal the extra weight." 4."When children are little, it's expected that they'll look a little chubby."
2."In most cases, medication and diet will control fluid retention."
The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic? 1.The entire bone fractured straight across 2.A greater risk of infection than a simple fracture 3.The bone being fractured but not producing a break in the skin 4.One side of the bone being broken and the other side being bent
2.A greater risk of infection than a simple fracture
A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which items during an episode of nausea? 1.Low-calorie foods 2.Cool, clear liquids 3.Low-protein foods 4.The child's favorite foods
2.Cool, clear liquids
The nurse is assisting with identifying clients in the community at risk for latex allergy. Which client population is most at risk for developing this type of allergy? 1.Children in day care centers 2.Individuals with spina bifida 3.Individuals with cardiac disease 4.Individuals living in group homes
2.Individuals with spina bifida
Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system? 1.Decrease in height 2.Overall sclerotic lesions 3.Diminished lean body mass 4.Change in structural bone tissue
2.Overall sclerotic lesions
An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL (72 mcmol/L) and receives treatment with lactulose syrup. The nurse determines that the client has the best response if the level changes to which after medication administration? 1. 2 mcg/dL (1.2 mcmol/L) 2. 5 mcg/dL (3 mcmol/L) 3. 70 mcg/dL (42 mcmol/L) 4. 100 mcg/dL (60 mcmol/L)
3. 70 mcg/dL (42 mcmol/L)
The nurse is monitoring the laboratory results of a client preparing to receive chemotherapy. The nurse determines that the white blood cell count (WBC) is normal if which result is present? 1. 2000 mm3 (2 × 109/L) 2. 3000 mm3 (3× 109/L) 3. 5000 mm3 (5 × 109/L) 4. 15,000 mm3 (15 × 109/L)
3. 5000 mm3 (5 × 109/L)
The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take? 1.Deliver the food tray to the client. 2.Replace the whole milk with lactose-free milk. 3.Call the dietary department and ask for a different meal. 4.Ask the dietary department to replace the beef with pork.
3. Call the dietary department and ask for a different meal.
The nurse assists with developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis? 1.Pain 2.Inadequate knowledge 3.Neurological dysfunction 4.Difficult family coping processes
3. Neurological dysfunction
The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching? 1."We need to encourage adequate fluid intake." 2."Coughing spells may be triggered by dust or smoke." 3."We need to maintain respiratory precautions and a quiet environment for at least 2 weeks." 4."Good hand-washing techniques need to be instituted to prevent spreading the disease to others."
3."We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."
A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse should prepare for which diagnostic study that can confirm this diagnosis? 1.A platelet count 2.A lumbar puncture 3.A bone marrow biopsy 4.A white blood cell (WBC) count
3.A bone marrow biopsy
The nurse is monitoring a client receiving glipizide. Which outcome indicates an ineffective response from the medication? 1.A decrease in polyuria 2.A decrease in polyphagia 3.A glycosylated hemoglobin level of 12% 4.A fasting plasma glucose of 100 mg/dL (5.7 mmol/L)
3.A glycosylated hemoglobin level of 12%
A client is taking lansoprazole for the chronic management of Zollinger-Ellison syndrome. If prescribed, which medication would be appropriate for the client if needed for a headache? 1.Naprosyn 2.Ibuprofen 3.Acetaminophen 4.Acetylsalicylic acid
3.Acetaminophen
The nurse assists with creating a plan of care for a client with hyperparathyroidism receiving calcitonin-human. Which outcome has the highest priority regarding this medication? 1.Relief of pain 2.Absence of side effects 3.Reaching normal serum calcium levels 4.Verbalization of appropriate medication knowledge
3.Reaching normal serum calcium levels
A client has been placed in Buck's extension traction. Which technique provided by the nurse will provide countertraction? 1.Using a footboard 2.Providing an overhead trapeze 3.Slightly elevating the foot of the bed 4.Slightly elevating the head of the bed
3.Slightly elevating the foot of the bed
A client is admitted to the hospital with possible rheumatic endocarditis. The nurse should check for a history of which type of infection? 1.Viral infection 2.Yeast infection 3.Streptococcal infection 4.Staphylococcal infection
3.Streptococcal infection
The nurse is assisting with preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which intervention is most appropriate for this child? 1.Provide a high-salt diet. 2.Provide a high-protein diet. 3.Discourage visitors at mealtimes. 4.Encourage the child to eat in the playroom.
4.Encourage the child to eat in the playroom.
Skin breakdown occurs on a client's hand at the site of an intravenous catheter that had medication infusing. The nurse determines that which adverse effect occurred? Refer to figure. 1.Phlebitis 2.Infiltration 3.Thrombosis 4.Extravasation
4.Extravasation
A client with chronic kidney disease is receiving ferrous sulfate. The nurse should monitor the client for which common side effect associated with this medication? 1.Diarrhea 2.Weakness 3.Headache 4.Constipation
4. Constipation
The nurse is caring for a postoperative client who has been NPO and the primary health care provider (PHCP) has prescribed a clear liquid diet. When planning to initiate this diet, which priority item should the nurse place at the client's bedside? 1.A straw 2.Code cart 3.Blood pressure cuff 4.Suction equipment
4. Suction equipment
A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia? 1.Sweating 2.Tachycardia 3.Nervousness 4.Low blood glucose
4. low blood glucose
The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy? 1."Antacids will coat my stomach." 2."Omeprazole will coat the ulcer and help it heal." 3."Sucralfate will change the fluid in my stomach." 4."The nizatidine will cause me to produce less stomach acid."
4."The nizatidine will cause me to produce less stomach acid."
The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area? 1.At the umbilicus 2.Just above the symphysis pubis 3.At the level of the xiphoid process 4.Midway between the symphysis pubis and the umbilicus
4.Midway between the symphysis pubis and the umbilicus
A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's poor nutritional intake. Which nursing intervention related to poor nutrition should be the initial choice? 1.Weigh the client three times per week, before breakfast. 2.Explain to the client the importance of a good nutritional intake. 3.Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible. 4.Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.
4.Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during these times.
A client who is taking hydrochlorothiazide has also been prescribed triamterene. The client asks the nurse why both medications are required. Which response is the most accurate to give to the client? 1.Both are weak potassium-excreting diuretics. 2.The combination of these medications prevents renal toxicity. 3.Hydrochlorothiazide is an expensive medication, so using a combination of diuretics is cost-effective. 4.Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide
4.Triamterene is a potassium-retaining (sparing) diuretic, whereas hydrochlorothiazide
A postoperative client requests medication for flatulence (gas pains). Which medication from the PRN list should the nurse administer to this client? 1.Ondansetron 2.Simethicone 3.Acetaminophen 4.Magnesium hydroxide
2.Simethicone
The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? 1.Flushed and warm skin 2.Eupnea and normal body temperature 3.Irregular, noisy breathing and cold, clammy skin 4.Presence of swallowing reflex and active bowel sounds
3.Irregular, noisy breathing and cold, clammy skin
The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure? 1.Discard used tissues in a plastic bag. 2.Wash hands at least four times a day. 3.Brush teeth and rinse the mouth once a day. 4.Turn the head to the side if coughing or sneezing.
1.Discard used tissues in a plastic bag.
The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions should the nurse use for communicating with the client? Select all that apply. 1.Face the client when talking. 2.Speak slowly and maintain eye contact. 3.Use gestures when talking to enhance words. 4.Avoid the use of body language when talking to the client. 5.Give the client directions using short phrases and simple terms. 6.Phrase what was said differently the second time, if there is a need to repeat it.
1.Face the client when talking. 2.Speak slowly and maintain eye contact. 3.Use gestures when talking to enhance words. 5.Give the client directions using short phrases and simple terms.
A primary health care provider (PHCP) prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank.
10 mL
The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.
2520 mL
The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome? 1.Common 2.Suggestive of anemia 3.Characteristic of a thrush infection 4.Indicative of a need to improve oral hygiene
3.Characteristic of a thrush infection
A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that their eyes are to be donated. Which action should the nurse take next? 1.Place dry, sterile dressings over the eyes of the deceased. 2.Call the National Donor Association to confirm that the client is a donor. 3.Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes. 4.Ask the wife to obtain the legal documents regarding organ donation from the lawyer.
3.Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.
The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? 1.Skin color becomes cyanotic. 2.Secretions are becoming bloody. 3.Coughing occurs with suctioning. 4.Heart rate decreases from 78 beats/minute to 54 beats/minute.
3.Coughing occurs with suctioning.
Before administering an intermittent tube feeding through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding? 1.Observe the digestion of formula. 2.Check fluid and electrolyte status. 3.Evaluate absorption of the last feeding. 4.Confirm proper nasogastric tube placement.
3.Evaluate absorption of the last feeding.
A depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as "I'm such a failure. I can't do anything right!" Which action should the nurse take? 1.Tell the client that this is not true and that we all have a purpose in life. 2.Remain with the client and sit in silence until the client verbalizes feelings. 3.Identify recent behaviors or accomplishments that demonstrate skill or ability. 4.Reassure the client that you know how the client is feeling and that things will get better.
3.Identify recent behaviors or accomplishments that demonstrate skill or ability.
A client who has begun taking fosinopril is very distressed, telling the nurse that he cannot taste food normally since beginning the medication 2 weeks ago. Which suggestion would provide the best support for the client? 1.Tell the client not to take the medication with food. 2.Suggest that the client taper the dose until taste returns to normal. 3.Inform the client that impaired taste is expected and generally disappears in 2 to 3 months. 4.Tell the client that a request will be made to the primary health care provider (PHCP) to change the prescription.
3.Inform the client that impaired taste is expected and generally disappears in 2 to 3 months.
A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include? 1.Try to exercise before mealtime. 2.Administer insulin after exercising. 3.Take a blood glucose test before exercising. 4.Exercise should be performed during peak times of insulin.
3.Take a blood glucose test before exercising.
A client had an aortic valve replacement 2 days ago. This morning, the client tells the nurse, "I don't feel any better than I did before surgery." Which response by the nurse is most appropriate? 1."You will feel better in a week or two." 2."It's only the second day postop. Cheer up." 3."This is a normal frustration. It'll get better." 4."You are concerned that you don't feel any better after surgery?
4."You are concerned that you don't feel any better after surgery
A client received 20 units of NPH insulin subcutaneously at 8:00 am. The nurse should check the client for a potential hypoglycemic reaction at which time? 1.9:00 am 2.12:00 Noon 3.1:00 pm 4.5:00 pm
4.5:00 pm
A mother is breastfeeding her newborn. The mother complains to the nurse that she is experiencing severe nipple soreness. The nurse should provide which suggestion to the client? 1.Avoid rotating breastfeeding positions so that the nipple will toughen. 2.Stop nursing during the period of nipple soreness to allow the nipples to heal. 3.Nurse the newborn infant less frequently and substitute a bottle feeding until the nipples become less sore. 4.Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
4.Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach against the mother's.
A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which information about the test? 1.The test may be painful. 2.Fluids will be restricted after the test. 3.The test takes approximately 2 to 3 hours. 4.The dye injected may cause a warm, flushing sensation.
4.The dye injected may cause a warm, flushing sensation.
The nurse observes that a client with a nasogastric tube connected to continuous gastric suction is mouth breathing, has dry mucous membranes, and has a foul breath odor. When planning care, which nursing intervention would be best to maintain the integrity of this client's oral mucosa? 1.Offer small sips of water frequently. 2.Encourage the client to suck on sour, hard candy. 3.Use lemon glycerin swabs to provide oral hygiene. 4.Use diluted mouthwash and water to swab the mouth after brushing teeth
4.Use diluted mouthwash and water to swab the mouth after brushing teeth
The nurse reinforces instructions to the client about breast self-examination (BSE). The nurse instructs the client to lie down and examine the left breast. Which is the correct area for placing a pillow when examining the left breast? 1.Under the left shoulder 2.Under the right scapula 3.Under the right shoulder 4.Under the small of the back
1.Under the left shoulder
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which should the nurse expect to note in this client? Select all that apply. 1.Hypocapnia 2.Dyspnea during exertion 3.Presence of a productive cough 4.Difficulty breathing while talking 5.Increased oxygen saturation with exercise 6.A shortened expiratory phase of respiration
2.Dyspnea during exertion 3.Presence of a productive cough 4.Difficulty breathing while talking
A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? 1.The client is at increased risk for suicide. 2.The client is dealing with pertinent issues. 3.The client may need some time off the unit. 4.The client is responding normally to hospitalization.
1.The client is at increased risk for suicide.
In planning activities for the depressed client, especially during the early stages of hospitalization, which action is best? 1.Plan nothing until the client asks to participate in the milieu. 2.Encourage the client to participate in a structured daily program of activities. 3.Give the client a menu of daily activities and insist that the client participate in all activities offered. 4.Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as drawing or reading a book.
2.Encourage the client to participate in a structured daily program of activities.
A client who has been taking isoniazid for 1½ months complains to the nurse about numbness, paresthesia, and tingling in the extremities. The nurse interprets that the client is experiencing which adverse effect? 1.Hypercalcemia 2.Peripheral neuritis 3.Small blood vessel spasm 4.Impaired peripheral circulation
2.Peripheral neuritis
The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. 1.Apply suction for up to 10 seconds. 2.Hyperoxygenate the client before suctioning. 3.Set the wall suction unit pressure at 160 mm Hg. 4.Apply suction while gently inserting the catheter. 5.Apply intermittent suction while rotating and withdrawing the catheter. 6.Advance the catheter until resistance is met and then pull the catheter back 1 cm.
1.Apply suction for up to 10 seconds. 2.Hyperoxygenate the client before suctioning. 5.Apply intermittent suction while rotating and withdrawing the catheter. 6.Advance the catheter until resistance is met and then pull the catheter back 1 cm.
The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method? 1.Asking the client to recap the needle 2.Placing the needle and syringe in a puncture-resistant container 3.Recapping the needle before placing it in a puncture-resistant container 4.Laying the needle and syringe on the bedside table and carefully recapping the needle
2.Placing the needle and syringe in a puncture-resistant container
The nurse is attempting to communicate with a hearing-impaired client. Which strategy by the nurse would be least helpful when talking to this client? 1.Reducing any background noise 2.Smiling continuously during conversation 3.Facing the client so that there is light on the nurse's face 4.Ensuring that showing frustration through facial expression is not done
2.Smiling continuously during conversation
The nurse is caring for a client who has been prescribed furosemide and is monitoring for adverse effects associated with this medication. Which should the nurse recognize as potential adverse effects? Select all that apply. 1.Nausea 2.Tinnitus 3.Hypotension 4.Hypokalemia 5.Photosensitivity 6.Increased urinary frequency
2.Tinnitus 3.Hypotension 4.Hypokalemia
The nurse is assigned to care for an infant with cryptorchidism. One testis cannot be palpated. The nurse anticipates that which diagnostic study will be prescribed to determine where the undescended testis is located in the body? 1.Cystocopy 2.Abdominal x-ray 3.Urodynamic study 4.Computed tomography scan
4.Computed tomography scan
The nurse reinforces client instructions about ethambutol. The nurse determines that the client understands the instructions if the client indicates to report which occurrence? 1.Impaired sense of hearing 2.Distressing gastrointestinal side effects 3.Orange-red discoloration of body secretions 4.Difficulty discriminating the color red from green
4.Difficulty discriminating the color red from green
The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which items into the client's room? 1.Nebulizer and pulse oximeter 2.Blood pressure cuff and flashlight 3.Flashlight and incentive spirometer 4.Electrocardiographic monitoring electrodes and intubation tray
4.Electrocardiographic monitoring electrodes and intubation tray
The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response by the student indicates an understanding of this physiological process? 1."Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high." 2."Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are low." 3."The low levels of estrogen and progesterone increase the release of follicle-stimulating hormone and luteinizing hormone." 4."The high levels of estrogen and progesterone promote the release of follicle-stimulating hormone and luteinizing hormone."
1."Ovulation ceases during pregnancy because the circulating levels of estrogen and progesterone are high."
The nurse is preparing to set up a sterile field using the principles of aseptic technique to perform a dressing change. Which should the nurse include in the preparations? Select all that apply. 1.Use a dry table that is below waist level. 2.Open the distal flap of a sterile package first. 3.Prepare the sterile field just before the planned procedure. 4.Don clean gloves before touching items on the sterile field. 5.Place the sterile field 1 foot behind the working area and out of view of the client. 6.Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.
2.Open the distal flap of a sterile package first. 3.Prepare the sterile field just before the planned 6.Avoid placing items within 1 inch of any area surrounding the outer edge of the sterile field.
A client asks the nurse about the causes of acne. The nurse should respond by making which statement to the client? 1."It is caused by oily skin." 2."The exact cause of acne is not known." 3."It occurs as a result of exposure to heat and humidity." 4."Acne is caused by eating chocolate, nuts, and fatty foods."
2."The exact cause of acne is not known."
The nurse is caring for an older client with a diagnosis of myasthenia gravis and has reinforced self-care instructions. Which statement by the client indicates a need for further teaching? 1."I rest each afternoon after my walk." 2."I cough and deep breathe many times during the day." 3."If I get abdominal cramps and diarrhea, I should call my doctor." 4."I can change the time of my medication on the mornings that I feel strong."
4."I can change the time of my medication on the mornings that I feel strong."
The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching? 1."I need to check for jaundiced skin and eyes every day." 2."I need to have my child nap during the day to provide rest." 3."I need to decrease the stimuli at home to prevent intracranial pressure." 4."I need to give frequent, small, nutritious meals if my child starts to vomit."
4."I need to give frequent, small, nutritious meals if my child starts to vomit."
